National Healthcare Security Administration Office Releases CHS-DRG Subgrouping Scheme (Version 1.0)

Just now, the General Office of the National Healthcare Security Administration issued the "Notice of the General Office of the National Healthcare Security Administration on Printing and Distributing the Subgrouping Scheme for China Healthcare Security Diagnosis-Related Groups (CHS-DRG) (Version 1.0) (No. 29 [2020] of the General Office of the NHSA)." The notice specifies that a total of 618 CHS-DRG subgroups shall serve as the basic units for DRG-based payment.

Pilot cities may develop their local DRG subgroups by referencing the detailed subgroups, or they may directly adopt the CHS-DRG subgroups to implement the national pilot program for DRG-based payment.

The body of the notice is as follows:

CHS-DRG Subgroups represent a further refinement of the 376 core Diagnosis Related Groups (ADRGs) outlined in the "National Healthcare Security Administration DRG (CHS-DRG) Grouping Scheme." Serving as the basic unit for DRG-based payment, these subgroups total 618. Pilot cities should formulate their local DRG subgroups by referencing the CHS-DRG subgrouping results, the Complications and Comorbidities/Major Complications and Comorbidities table (CC&MCC Table), grouping rules, and naming conventions. Depending on local circumstances, pilot cities may also directly adopt the CHS-DRG subgroups to implement the national pilot program for local DRG-based payment.

The medical insurance management departments of all pilot medical institutions shall coordinate with the medical records, information technology, and finance departments to implement quality control over relevant data sources, ensuring that all indicators in the Medical Security Fund Settlement List are authentic, accurate, and traceable. A unique identifier variable shall be established for both the Medical Security Fund Settlement List and the Detailed Medical Service Information Table (Form KC22), and linkage between these datasets shall be properly maintained to ensure the completeness of patient-specific information, which shall be submitted to the medical insurance departments of the pilot cities in accordance with regulations. The medical insurance departments of all pilot cities shall strengthen the upgrading of their information systems and improve mechanisms for the submission, review, and feedback of the Medical Security Fund Settlement List and detailed medical service information.

Each pilot city shallBy August 31Submit the evaluation report to the National Pilot Technical Guidance Group for DRG-based Payment (hereinafter referred to as the “Technical Guidance Group”). Work in the simulation phase may commence only after review and approval. During the simulation phase, pilot city healthcare security administrations shall strengthen communication and feedback with pilot medical institutions to establish a unified and efficient working mechanism.

Pilot cities utilizing local DRG subgroups shall continuously optimize and refine their subgrouping schemes during simulation runs, under the premise that the ADRG grouping remains unchanged. Pilot cities adopting CHS-DRG subgroups shall establish a collaborative mechanism with the Technical Guidance Group, actively participate in the dynamic maintenance of DRG subgroups, maintain disease diagnosis and surgical procedure codes, submit grouping-related data, conduct clinical validations, and support the improvement of CHS-DRG subgroup versions.

All regions should further clarify corresponding policy measures during the simulation phase. First, formulate and improve policies related to weight adjustments, global budget management, and settlement and reconciliation. Second, conduct comparative studies. Compare changes between DRG-based simulated payment and existing payment methods in terms of fund expenditures, patient financial burden, revenue and operational efficiency of medical institutions, and medical practices. Third, strengthen research on regulatory systems adapted to the characteristics of DRG payment, and develop targeted measures to address potential behaviors such as service reduction, upcoding, unbundling of hospitalizations, and patient dumping.